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May 7, 2014

Inpatient Admit to Skilled Nursing Facility - Ohio – Will Not Advance to Complex Review

The J15 Part A Medical Review department performed a service-specific probe review on inpatient services relating to hospital admissions which resulted in admission to skilled nursing facilities, bill type 11X, in Ohio. Although results demonstrated that additional medical review efforts may be indicated, due to a change in the medical review strategy, CGS will not advance this probe edit to ongoing complex review at this time. We may conduct additional reviews related to these services in the future.

Ohio-Probe Edit Results: Inpatient Admit to Skilled Nursing Facility
  Charges Claims
Reviewed $711,882.43 95
Denied $201,571.02 29
Charge Denial Rate 29.7%  

The top denial reasons associated with this review are:

Denial Code 5J504 — Need for Service/Item Not Medically and Reasonably Necessary

  • Reason for denial:
    • The documentation submitted for review did not support the medical necessity of the services provided
  • How to prevent denials:
    • Submit documentation to support that all services were medically necessary on an inpatient basis instead of a less intensive setting.
    • Documentation should include all clinical information for the dates of service billed such as physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse's notes, consultations, surgical procedures, orders and discharge summary and any other documentation to support the inpatient admission.
    • Include documentation of services, medication and medical interventions performed in the Emergency Department.
    • For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes.
  • For more information, refer to:

Denial Code 56900 — Records Not Submitted

  • Reason for denial:
    • The medical records were not received in response to an Additional Documentation Request (ADR) in the required time frame; therefore, we were unable to determine medical necessity.
  • How to prevent denials:
    • Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted. Please note: CGS may request records through our Medical Review or Claims departments, and other contractors such as the Zone Program Integrity Contractor (ZPIC) may also request records. Ensure the records are submitted to the appropriate entity.
    • Alert your mail room staff to be aware of any mail you receive from CGS.
    • Be aware of the need to submit medical records within 30 days of the date on the Additional Documentation Request (ADR) in the upper left corner.
    • Gather all information and submit at one time.
    • Submit medical records as soon as the ADR is received.
    • Attach a copy of the ADR to each individual claim.
    • If you are responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
    • Do not mail packages COD; we cannot accept them.
    • Return the medical records to the address indicated in the ADR.
  • For more information, refer to:

Individual providers with significant denials will be contacted for one-on-one education.

If you have questions regarding this review, please contact the Medical Review department at 803.763.4999.


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